Font Size

Pharmacy Prior Authorization

Pharmacy fee for service Prior Authorization (PA)  Contacts

Change Healthcare Pharmacy PA Unit
Toll-free: 877-537-0722
Fax: 877-537-0720

Mississippi Medicaid Prescribers

Registered Users
If you are a Mississippi Medicaid prescriber, submit your prior authorization requests through the Change Healthcare provider portal.

All providers should register at the following link to submit prior authorization requests:

Those Without Web Portal Access
For Mississippi Medicaid prescribers who are unable to submit prior authorizations through the Envision web portal, fax your request to Change Healthcare Pharmacy PA unit.

Drug Prior Authorization Instructions

Prior Authorization Packets Updated
Brand Name Multi-Source 11/1/2018
Early Refill 11/1/2018
Enteral Nutrition 11/1/2018
EPSDT – Beneficiaries Under 21 11/1/2018
Heterozygous Familial Hypercholesterolemia (HeFH) – REPATHA™ (EVOLOCUMAB) and PRALUENT® (ALIROCUMAB) 11/1/2018
Hepatitis C Therapy 11/1/2018
Homozygous Familial Hypercholesterolemia (HoFH) – REPATHA™ (EVOLOCUMAB) 11/1/2018
Max Unit Override 11/1/2018
Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) 11/1/2018
PDL Exception Request 11/1/2018
RSV-SYNAGIS® 11/1/2018
Universal Prior Authorization Form 11/1/2018


Manual Prior Authorization Criteria
Pharmacy Reconsideration Request Form
MedWatch Form

Translate »